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Müller AR, den Hollander B, van de Ven PM, Roes KCB, Geertjens L, Bruining H, van Karnebeek CDM, Jansen FE, de Wit MCY, Ten Hoopen LW, Rietman AB, Dierckx B, Wijburg FA, Boot E, Brands MMG, van Eeghen AM. Cannabidiol (Epidyolex®) for severe behavioral manifestations in patients with tuberous sclerosis complex, mucopolysaccharidosis type III and fragile X syndrome: protocol for a series of randomized, placebo-controlled N-of-1 trials. BMC Psychiatry 2024; 24:23. [PMID: 38177999 PMCID: PMC10768432 DOI: 10.1186/s12888-023-05422-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/29/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Many rare genetic neurodevelopmental disorders (RGNDs) are characterized by intellectual disability (ID), severe cognitive and behavioral impairments, potentially diagnosed as a comorbid autism spectrum disorder or attention-deficit hyperactivity disorder. Quality of life is often impaired due to irritability, aggression and self-injurious behavior, generally refractory to standard therapies. There are indications from previous (case) studies and patient reporting that cannabidiol (CBD) may be an effective treatment for severe behavioral manifestations in RGNDs. However, clear evidence is lacking and interventional research is challenging due to the rarity as well as the heterogeneity within and between disease groups and interindividual differences in treatment response. Our objective is to examine the effectiveness of CBD on severe behavioral manifestations in three RGNDs, including Tuberous Sclerosis Complex (TSC), mucopolysaccharidosis type III (MPS III), and Fragile X syndrome (FXS), using an innovative trial design. METHODS We aim to conduct placebo-controlled, double-blind, block-randomized, multiple crossover N-of-1 studies with oral CBD (twice daily) in 30 patients (aged ≥ 6 years) with confirmed TSC, MPS III or FXS and severe behavioral manifestations. The treatment is oral CBD up to a maximum of 25 mg/kg/day, twice daily. The primary outcome measure is the subscale irritability of the Aberrant Behavior Checklist. Secondary outcome measures include (personalized) patient-reported outcome measures with regard to behavioral and psychiatric outcomes, disease-specific outcome measures, parental stress, seizure frequency, and adverse effects of CBD. Questionnaires will be completed and study medication will be taken at the participants' natural setting. Individual treatment effects will be determined based on summary statistics. A mixed model analysis will be applied for analyzing the effectiveness of the intervention per disorder and across disorders combining data from the individual N-of-1 trials. DISCUSSION These N-of-1 trials address an unmet medical need and will provide information on the effectiveness of CBD for severe behavioral manifestations in RGNDs, potentially generating generalizable knowledge at an individual-, disorder- and RGND population level. TRIAL REGISTRATION EudraCT: 2021-003250-23, registered 25 August 2022, https://www.clinicaltrialsregister.eu/ctr-search/trial/2021-003250-23/NL .
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Affiliation(s)
- A R Müller
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- 's Heeren Loo Care Group, Amersfoort, The Netherlands
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, the Netherlands
| | - B den Hollander
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, the Netherlands
- United for Metabolic Diseases, Amsterdam, The Netherlands
| | - P M van de Ven
- Department of Data Science and Biostatistics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - K C B Roes
- Department of Health Evidence, Biostatistics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - L Geertjens
- Child and Adolescent Psychiatry and Psychosocial Care, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
- Amsterdam UMC, Amsterdam Neuroscience, Amsterdam Reproduction and Development, N=You Neurodevelopmental Precision Center, Amsterdam, The Netherlands
| | - H Bruining
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, the Netherlands
- Child and Adolescent Psychiatry and Psychosocial Care, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
- Amsterdam UMC, Amsterdam Neuroscience, Amsterdam Reproduction and Development, N=You Neurodevelopmental Precision Center, Amsterdam, The Netherlands
- Levvel, Center for Child and Adolescent Psychiatry, Amsterdam, The Netherlands
| | - C D M van Karnebeek
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, the Netherlands
- United for Metabolic Diseases, Amsterdam, The Netherlands
- Department of Human Genetics, Amsterdam UMC, Amsterdam, The Netherlands
| | - F E Jansen
- Department of Pediatric Neurology, Brain, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M C Y de Wit
- ENCORE Expertise Center for Neurodevelopmental Disorders, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - L W Ten Hoopen
- ENCORE Expertise Center for Neurodevelopmental Disorders, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Child and Adolescent Psychiatry/Psychology, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - A B Rietman
- ENCORE Expertise Center for Neurodevelopmental Disorders, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Child and Adolescent Psychiatry/Psychology, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - B Dierckx
- ENCORE Expertise Center for Neurodevelopmental Disorders, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Child and Adolescent Psychiatry/Psychology, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - F A Wijburg
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - E Boot
- 's Heeren Loo Care Group, Amersfoort, The Netherlands
- The Dalglish Family 22Q Clinic, Toronto, ON, Canada
- Department of Psychiatry & Neuropsychology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - M M G Brands
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, the Netherlands
- United for Metabolic Diseases, Amsterdam, The Netherlands
| | - A M van Eeghen
- Department of Pediatrics, Emma Children's Hospital, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands.
- 's Heeren Loo Care Group, Amersfoort, The Netherlands.
- Emma Center for Personalized Medicine, Amsterdam UMC, Amsterdam, the Netherlands.
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Müller AR, Zinkstok JR, Rommelse NNJ, van de Ven PM, Roes KCB, Wijburg FA, de Rooij-Askes E, Linders C, Boot E, van Eeghen AM. Methylphenidate for attention-deficit/hyperactivity disorder in patients with Smith-Magenis syndrome: protocol for a series of N-of-1 trials. Orphanet J Rare Dis 2021; 16:380. [PMID: 34496899 PMCID: PMC8424817 DOI: 10.1186/s13023-021-02003-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 08/24/2021] [Indexed: 12/29/2022] Open
Abstract
Background Smith–Magenis syndrome (SMS) is a rare genetic neurodevelopmental disorder characterized by intellectual disability and severe behavioural and sleep disturbances. Often, patients with SMS are diagnosed with attention-deficit/hyperactivity disorder (ADHD). However, the effectiveness of methylphenidate (MPH), the first-line pharmacological treatment for ADHD, in patients with SMS is unclear. Our objective is to examine the effectiveness of MPH for ADHD symptoms in individuals with SMS, proposing an alternative trial design as traditional randomized controlled trials are complex in these rare and heterogeneous patient populations. Methods and analysis We will initiate an N-of-1 series of double-blind randomized and placebo-controlled multiple crossover trials in six patients aged ≥ 6 years with a genetically confirmed SMS diagnosis and a multidisciplinary established ADHD diagnosis, according to a power analysis based on a summary measures analysis of the treatment effect. Each N-of-1 trial consists of a baseline period, dose titration phase, three cycles each including randomized intervention, placebo and washout periods, and follow-up. The intervention includes twice daily MPH (doses based on age and body weight). The primary outcome measure will be the subscale hyperactivity/inattention of the Strengths and Difficulties Questionnaire (SDQ), rated daily. Secondary outcome measures are the shortened version of the Emotion Dysregulation Inventory (EDI) reactivity index, Goal Attainment Scaling (GAS), and the personal questionnaire (PQ). Statistical analysis will include a mixed model analysis. All subjects will receive an assessment of their individual treatment effect and data will be aggregated to investigate the effectiveness of MPH for ADHD in SMS at a population level. Conclusions This study will provide information on the effectiveness of MPH for ADHD in SMS, incorporating personalized outcome measures. This protocol presents the first properly powered N-of-1 study in a rare genetic neurodevelopmental disorder, providing a much-needed bridge between science and practice to optimize evidence-based and personalized care. Trial registration This study is registered in the Netherlands Trial Register (NTR9125).
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Affiliation(s)
- A R Müller
- Advisium, 's Heeren Loo, Amersfoort, the Netherlands.,Department of Pediatrics, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - J R Zinkstok
- Department of Psychiatry and Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - N N J Rommelse
- Karakter, Child and Adolescent Psychiatry, Nijmegen, The Netherlands.,Department of Psychiatrics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - P M van de Ven
- Department of Epidemiology and Data Science, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - K C B Roes
- Department of Health Evidence, Biostatistics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - F A Wijburg
- Department of Pediatrics, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | - C Linders
- Advisium, 's Heeren Loo, Amersfoort, the Netherlands
| | - E Boot
- Advisium, 's Heeren Loo, Amersfoort, the Netherlands.,Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands.,The Dalglish Family 22Q Clinic, University Health Network, Toronto, ON, Canada
| | - A M van Eeghen
- Advisium, 's Heeren Loo, Amersfoort, the Netherlands. .,Department of Pediatrics, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands.
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Auger M, Auty DJ, Barbeau PS, Beauchamp E, Belov V, Benitez-Medina C, Breidenbach M, Brunner T, Burenkov A, Cleveland B, Cook S, Daniels T, Danilov M, Davis CG, Delaquis S, deVoe R, Dobi A, Dolinski MJ, Dolgolenko A, Dunford M, Fairbank W, Farine J, Feldmeier W, Fierlinger P, Franco D, Giroux G, Gornea R, Graham K, Gratta G, Hall C, Hall K, Hargrove C, Herrin S, Hughes M, Johnson A, Johnson TN, Karelin A, Kaufman LJ, Kuchenkov A, Kumar KS, Leonard DS, Leonard F, Mackay D, MacLellan R, Marino M, Mong B, Montero Díez M, Müller AR, Neilson R, Nelson R, Odian A, Ostrovskiy I, O'Sullivan K, Ouellet C, Piepke A, Pocar A, Prescott CY, Pushkin K, Rowson PC, Russell JJ, Sabourov A, Sinclair D, Slutsky S, Stekhanov V, Tolba T, Tosi D, Twelker K, Vogel P, Vuilleumier JL, Waite A, Walton T, Weber M, Wichoski U, Wodin J, Wright JD, Yang L, Yen YR, Zeldovich OY. Search for neutrinoless double-beta decay in 136Xe with EXO-200. Phys Rev Lett 2012; 109:032505. [PMID: 22861843 DOI: 10.1103/physrevlett.109.032505] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Indexed: 06/01/2023]
Abstract
We report on a search for neutrinoless double-beta decay of 136Xe with EXO-200. No signal is observed for an exposure of 32.5 kg yr, with a background of ∼1.5×10(-3) kg(-1) yr(-1) keV(-1) in the ±1σ region of interest. This sets a lower limit on the half-life of the neutrinoless double-beta decay T(1/2)(0νββ)(136Xe)>1.6×10(25) yr (90% C.L.), corresponding to effective Majorana masses of less than 140-380 meV, depending on the matrix element calculation.
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Affiliation(s)
- M Auger
- LHEP, Albert Einstein Center, University of Bern, Bern, Switzerland
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Ackerman N, Aharmim B, Auger M, Auty DJ, Barbeau PS, Barry K, Bartoszek L, Beauchamp E, Belov V, Benitez-Medina C, Breidenbach M, Burenkov A, Cleveland B, Conley R, Conti E, Cook J, Cook S, Coppens A, Counts I, Craddock W, Daniels T, Danilov MV, Davis CG, Davis J, deVoe R, Djurcic Z, Dobi A, Dolgolenko AG, Dolinski MJ, Donato K, Dunford M, Fairbank W, Farine J, Fierlinger P, Franco D, Freytag D, Giroux G, Gornea R, Graham K, Gratta G, Green MP, Hägemann C, Hall C, Hall K, Haller G, Hargrove C, Herbst R, Herrin S, Hodgson J, Hughes M, Johnson A, Karelin A, Kaufman LJ, Koffas T, Kuchenkov A, Kumar A, Kumar KS, Leonard DS, Leonard F, LePort F, Mackay D, MacLellan R, Marino M, Martin Y, Mong B, Díez MM, Morgan P, Müller AR, Neilson R, Nelson R, Odian A, O'Sullivan K, Ouellet C, Piepke A, Pocar A, Prescott CY, Pushkin K, Rivas A, Rollin E, Rowson PC, Russell JJ, Sabourov A, Sinclair D, Skarpaas K, Slutsky S, Stekhanov V, Strickland V, Swift M, Tosi D, Twelker K, Vogel P, Vuilleumier JL, Vuilleumier JM, Waite A, Waldman S, Walton T, Wamba K, Weber M, Wichoski U, Wodin J, Wright JD, Yang L, Yen YR, Zeldovich OY. Observation of two-neutrino double-beta decay in 136Xe with the EXO-200 detector. Phys Rev Lett 2011; 107:212501. [PMID: 22181874 DOI: 10.1103/physrevlett.107.212501] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2011] [Indexed: 05/31/2023]
Abstract
We report the observation of two-neutrino double-beta decay in (136)Xe with T(1/2) = 2.11 ± 0.04(stat) ± 0.21(syst) × 10(21) yr. This second-order process, predicted by the standard model, has been observed for several nuclei but not for (136)Xe. The observed decay rate provides new input to matrix element calculations and to the search for the more interesting neutrinoless double-beta decay, the most sensitive probe for the existence of Majorana particles and the measurement of the neutrino mass scale.
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Affiliation(s)
- N Ackerman
- SLAC National Accelerator Laboratory, Stanford, California, USA
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LePort F, Neilson R, Barbeau PS, Barry K, Bartoszek L, Counts I, Davis J, deVoe R, Dolinski MJ, Gratta G, Green M, Montero Díez M, Müller AR, O'Sullivan K, Rivas A, Twelker K, Aharmim B, Auger M, Belov V, Benitez-Medina C, Breidenbach M, Burenkov A, Cleveland B, Conley R, Cook J, Cook S, Craddock W, Daniels T, Dixit M, Dobi A, Donato K, Fairbank W, Farine J, Fierlinger P, Franco D, Giroux G, Gornea R, Graham K, Green C, Hägemann C, Hall C, Hall K, Hallman D, Hargrove C, Herrin S, Hughes M, Hodgson J, Juget F, Kaufman LJ, Karelin A, Ku J, Kuchenkov A, Kumar K, Leonard DS, Lutter G, Mackay D, MacLellan R, Marino M, Mong B, Morgan P, Odian A, Piepke A, Pocar A, Prescott CY, Pushkin K, Rollin E, Rowson PC, Schmoll B, Sinclair D, Skarpaas K, Slutsky S, Stekhanov V, Strickland V, Swift M, Vuilleumier JL, Vuilleumier JM, Wichoski U, Wodin J, Yang L, Yen YR. A magnetically driven piston pump for ultra-clean applications. Rev Sci Instrum 2011; 82:105114. [PMID: 22047336 DOI: 10.1063/1.3653391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
A magnetically driven piston pump for xenon gas recirculation is presented. The pump is designed to satisfy extreme purity and containment requirements, as is appropriate for the recirculation of isotopically enriched xenon through the purification system and large liquid xenon time projection chamber of EXO-200. The pump, using sprung polymer gaskets, is capable of pumping more than 16 standard liters per minute of xenon gas with 750 Torr differential pressure.
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Affiliation(s)
- F LePort
- Department of Physics, Stanford University, Stanford, California 94305, USA
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Sinclair D, Rollin E, Smith J, Mommers A, Ackeran N, Aharmin B, Auger M, Barbeau PS, Benitez-Medina C, Breidenbach M, Burenkov A, Cook S, Coppens A, Daniels T, DeVoe R, Dobi A, Dolinski MJ, Donato K, Fairbank W, Farine J, Giroux G, Gornea G, Graham K, Gratta G, Green M, Hagemann C, Hall C, Hall K, Hallman D, Hargrove C, Herrin S, Kaufman LK, Leonard DS, LePort F, Mackay D, MacLennan R, Mong B, Díez MM, Müller AR, Neilson R, Niner E, Odian A, O'Sullivan K, Ouellet C, Piepke A, Pocar A, Prescott CY, Pushkin K, Rowson PC, Slutsky S, Stekhanov V, Twelker K, Voskanian N, Vuilleumier JL, Wichoski U, Wodin J, Yang L, Yen YR. Prospects for Barium Tagging in Gaseous Xenon. ACTA ACUST UNITED AC 2011. [DOI: 10.1088/1742-6596/309/1/012005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Montero Díez M, Twelker K, Fairbank W, Gratta G, Barbeau PS, Barry K, DeVoe R, Dolinski MJ, Green M, LePort F, Müller AR, Neilson R, O'Sullivan K, Ackerman N, Aharmin B, Auger M, Benitez-Medina C, Breidenbach M, Burenkov A, Cook S, Daniels T, Donato K, Farine J, Giroux G, Gornea R, Graham K, Hagemann C, Hall C, Hall K, Hallman D, Hargrove C, Herrin S, Karelin A, Kaufman LJ, Kuchenkov A, Kumar K, Lacey J, Leonard DS, Mackay D, MacLellan R, Mong B, Niner E, Odian A, Piepke A, Pocar A, Prescott CY, Pushkin K, Rollin E, Rowson PC, Sinclair D, Slutsky S, Stekhanov V, Vuilleumier JL, Wichoski U, Wodin J, Yang L, Yen YR. A simple radionuclide-driven single-ion source. Rev Sci Instrum 2010; 81:113301. [PMID: 21133463 DOI: 10.1063/1.3499505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
We describe a source capable of producing single barium ions through nuclear recoils in radioactive decay. The source is fabricated by electroplating (148)Gd onto a silicon α-particle detector and vapor depositing a layer of BaF(2) over it. (144)Sm recoils from the alpha decay of (148)Gd are used to dislodge Ba(+) ions from the BaF(2) layer and emit them in the surrounding environment. The simultaneous detection of an α particle in the substrate detector allows for tagging of the nuclear decay and of the Ba(+) emission. The source is simple, durable, and can be manipulated and used in different environments. We discuss the fabrication process, which can be easily adapted to emit most other chemical species, and the performance of the source.
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Affiliation(s)
- M Montero Díez
- Department of Physics, Stanford University, Stanford, California 94305, USA
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Braun F, Hosseini M, Wieland E, Sattler B, Laabs S, Lorf T, Müller AR, Fändrich F, Kremer B, Ringe B. Expression of E-selectin and its transcripts during intestinal ischemia-reperfusion injury in pigs. Transplant Proc 2004; 36:265-6. [PMID: 15050129 DOI: 10.1016/j.transproceed.2004.01.081] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Ischemia-reperfusion injury (IRI) can result in severe organ dys- or nonfunction. Interaction of leukocytes and endothelial cells mediated by E-selectin appears to be a key step for disturbed microcirculation. Therefore we studied gene and protein expression as well as localization of E-selectin during intestinal IRI. METHODS Intestinal tissue samples were obtained from extracorporeal perfused intestines (cold ischemia time [CIT] 2 or 20 hours, each n = 5) and additionally in intestinal transplanted pigs (CIT 2 or 20 hours, each n = 1). Mucosal damage was graded according to the Chiu classification. E-selectin mRNA was determined by PCR and quantitative RT-PCR. Localization of E-selectin mRNA was performed by in situ hybridization and of the protein by immunohistochemistry. RESULTS Histologically, mucosal damage occurred during reperfusion and was earlier and more severe after 20 hours of CIT. E-selectin mRNA expression was detected by PCR already after laparotomy and was elevated after reperfusion. Interestingly, mRNA expression was already increased after 20 hours of CIT. E-selectin mRNA was localized to the luminal surface of muscular, submucosal, and mucosal endothelial cells and the protein was detected on submucosal arterial endothelium as early as 2 hours after reperfusion. CONCLUSION Prolongation of CIT results in more severe mucosal damage during reperfusion, which is associated with protein expression of E-selection that might be used as a marker for activated endothelial cells. Increased E-selectin mRNA at end of 20 hours of CIT might indicate a preactivated state of endothelial cells potentially triggered by bacterial translocation or products.
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Affiliation(s)
- F Braun
- Klinik für Allgemeine Chirurgie und Thoraxchirurgie, Universität Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Braun F, Hosseini M, Wieland E, Sattler B, Müller AR, Fändrich F, Kremer B, Ringe B. Kinetics and localization of interleukin-2, interleukin-6, heat shock protein 70, and interferon gamma during intestinal-rerfusion injury. Transplant Proc 2004; 36:267-9. [PMID: 15050130 DOI: 10.1016/j.transproceed.2004.01.082] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Intestinal ischemia-reperfusion injury (IRI) represents an exaggerated inflammatory cascade with a complex pathophysiology. IL-2, IL-6, HSP70, and INF-gamma are mediators of the inflammatory process. Therefore, we investigated their kinetics and localization during intestinal IRI. METHODS Pig intestinal specimens were obtained during cold preservation (cold ischemia time 2 hours) and extracorporeal perfusion. Mucosal damage was graded according to the Chiu classification. MRNA expression was determined by Northern blot (IL-2, IL-6, IFN-gamma) or by quantitative RT-PCR (IL-6, HSP70) and localized by in situ hybridization. RESULTS Histologically, mucosal damage occurred during reperfusion. Expression of IL-2 mRNA was up-regulated after HTK perfusion and was highest at the start and 7 hours after reperfusion. Expression of IL-6 mRNA increased at 2 hours after reperfusion and HSP70 at 3 hours after reperfusion. IFN-gamma mRNA was expressed after HTK perfusion, with expression of this cytokine increasing to 1 hour after the start of reperfusion, and decreasing thereafter. IL-2 mRNA was localized to endothelial cells (EC) and leukocytes and in close relation to ganglion cells (GC): IL-6 mRNA in EC, smooth muscle cells (SMC), and GC: HSP70 mRNA in EC and SMC; and IFN-gamma mRNA in leukocytes. CONCLUSION IL-2, IL-6, HSP70, and INF-gamma are parameters of early mRNA expression during intestinal IRI. EC, SMC, leukocytes, and GC have been identified as sources of transcripts that might afford potential targets for intervention strategies to attenuate IRI.
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Affiliation(s)
- F Braun
- Klinik für Allgemeine Chirurgie und Thoraxchirurgie, Universität Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Golling M, Becker T, Broelsch C, Candinas D, Faust D, Fischer L, Geissler E, Graeb C, Iberer F, Klupp J, Kraus T, Müller AR, Neuhaus P, Strassburg CP, Wolff M, Zülke C, Bechstein WO. Konsensusempfehlung zum Einsatz von Sirolimus in der Lebertransplantation. Z Gastroenterol 2004; 42:1333-40. [PMID: 15558447 DOI: 10.1055/s-2004-813703] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Sirolimus is an m-TOR inhibitor without renal side effects and potentially protects against the development of malignancy. Due to a higher incidence of complications in two trials and an official warning in the drug information, the use of Sirolimus in liver transplantation is limited. The participants of this consensus meeting had to analyse and evaluate the literature with respect to the potential role of Sirolimus in liver transplantation. This consensus statement follows the scheme normally employed for the presentation of guidelines including the grading of evidence (1a-5) and the extent of recommendation (A-C). Moreover, the consensus included the experience of the authors with respect to the handling of Sirolimus after liver transplantation.
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Affiliation(s)
- M Golling
- Klinik für Allgemein- und Gefässchirurgie am Klinikum der Johann-Wolfgang-Goethe-Universität, Frankfurt am Main
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11
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Seehofer D, Rayes N, Schiller R, Stockmann M, Müller AR, Schirmeier A, Schaeper F, Tullius SG, Bengmark S, Neuhaus P. Probiotics partly reverse increased bacterial translocation after simultaneous liver resection and colonic anastomosis in rats. J Surg Res 2004; 117:262-71. [PMID: 15047132 DOI: 10.1016/j.jss.2003.11.021] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2003] [Indexed: 11/20/2022]
Abstract
BACKGROUND Bacterial translocation is one important cause of nosocomial infections following major abdominal surgery. Oral administration of probiotics has been proposed to diminish bacterial translocation. MATERIAL AND METHODS In total 68 rats were divided into seven groups: five of the groups received standard rat chow and were subjected to either sham-operation, 70% liver resection, colonic anastomosis, or a combination of 30 or 70% liver resection with synchronous colonic anastomosis, respectively. In two additional groups with synchronous operation, a combination of four different lactic acid bacteria and four fibers was administered two times daily pre- and postoperatively. Bacterial concentrations in cecum, mesenteric lymph nodes, liver, and spleen were analyzed and blood cultures were taken 48 h after operation. Furthermore, the following parameters were assessed: histological changes in the intestine, intestinal paracellular permeability (Ussing chamber), bursting pressure of the colonic anastomosis, and mitosis rate of the remnant liver. RESULTS Bacterial translocation was observed in all rats, except in the sham group. Following liver resection, the highest bacterial concentrations were seen in liver and spleen, following colon anastomosis in the mesenteric lymph nodes. Bacterial translocation was increased in the animals with combined operation, in parallel to the extent of liver resection. In rats with colon anastomosis, bacterial concentration in the cecum was also higher than in the sham group. Application of probiotics significantly decreased bacterial concentration in the lymph nodes. In addition, animals with a high cecal concentration of lactobacilli had less translocation than the others. No histological changes were observed in the intestine. Paracellular permeability for ions, but not for the larger molecule lactulose, was increased in the colon in all groups with colon anastomosis. The bursting pressure of the colon anastomosis was not significantly different between the groups. Seventy percent liver resection led to a high rate of hepatocyte mitosis, whereas combination with colon anastomosis impaired the regeneration process. CONCLUSION Synchronous liver resection and colon anastomosis led to increased bacterial translocation compared to the single operations in the rat model. It is possible to diminish this process by oral administration of probiotics. Bacterial overgrowth in the cecum and impaired hepatic regeneration, but not histological changes or alterations of paracellular permeability, are potential pathogenic mechanisms for translocation in this setting.
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Affiliation(s)
- Daniel Seehofer
- Department of General, Visceral, and Transplant Surgery, Charité, Campus Virchow, Humboldt University of Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany.
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12
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Müller AR, Pascher A, Platz KP, Neuhaus P. [Small bowel transplantation - current status and initial results]. Zentralbl Chir 2003; 128:849-55. [PMID: 14628234 DOI: 10.1055/s-2003-44343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
During the last years, clinical small bowel transplantation has significantly improved. This is especially true for isolated small bowel transplantation with success rates of 80 % 1-year patient survival. Currently, approximately 100 small bowel transplantations are performed per year worldwide. In Germany, small bowel transplantation is still rare, because of the high risk for the development of acute rejection and rejection-associated complications. This includes peritonitis and sepsis as well as over-immunosuppression-associated infections. Due to improvements in immunosuppression, the incidence of acute rejection decreased from about 85 % below 25 %. Half of the patients will receive a combined liver-small bowel graft due to TPN (total parenteral nutrition)-associated liver cirrhosis. Although the combined procedure has immunological advantages, complication rates are high and patient survival is significantly lower (ca. 50 % at 1 year). Next to bacterial, fungal, and atypic infections, which are frequently associated with rejection and other complications, CMV and EBV infections are of significant interest. This is of special importance for EBV infections, since all PTLD (lymphoproliferative disease) after small bowel transplantation are EBV-associated so far. Viral infections should be monitored and preemptive therapy using ganciclovir or foscavir will be initiated. Of the 800 patients transplanted so far, 50 % are still alive up to 15 years. Of these, more than 80 % are off parenteral nutrition, in good healths, with good quality of live.
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Affiliation(s)
- A R Müller
- Klinik für Allgemeine- und Thoraxchirurgie, Universitätsklinikum Schleswig-Holstein, Campus Kiel.
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13
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Sauer IM, Kardassis D, Zeillinger K, Pascher A, Gruenwald A, Pless G, Irgang M, Kraemer M, Puhl G, Frank J, Müller AR, Steinmüller T, Denner J, Neuhaus P, Gerlach JC. Clinical extracorporeal hybrid liver support--phase I study with primary porcine liver cells. Xenotransplantation 2003; 10:460-9. [PMID: 12950989 DOI: 10.1034/j.1399-3089.2003.00062.x] [Citation(s) in RCA: 150] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The objective of this study was to evaluate the feasibility and safety of a hybrid liver support system with extracorporeal plasma separation and bioreactor perfusion in patients with acute liver failure (ALF) who had already fulfilled the criteria for high urgency liver transplantation (LTx). Eight patients (one male, seven female) were treated in terms of bridging to transplantation. The mean age was 36.5 yr (range 20 to 58). Etiology of liver failure was drug-related in two patients, hepatitis B infection in three patients, and unknown for three patients. The bioreactors were charged with primary liver cells from specific pathogen-free pigs. Cell viability varied between 91 and 98%. Continuous liver support treatment over a period of 8 to 46 h (mean 27.3 h) was safely performed and well-tolerated by all patients. No complications associated with the therapy were observed during the follow-up period. Thrombocytopenia was considered to be an effect of the plasma separation. Subsequently, all patients were transplanted successfully and were observed over at least 3 yr with an organ and patient survival rate of 100%. Screening of patient's sera for antibodies specific for porcine endogenous retroviruses (PERVs) showed no reactivity--either prior to application of the system, or after extracorporeal treatment. The results encourage us to continue the development of the technology, and further studies appear to be justified. The bioreactor technology has been integrated into a modular extracorporeal liver support (MELS) system, combining biologic liver support with artificial detoxification technology.
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Affiliation(s)
- I M Sauer
- General, Visceral and Transplantation Surgery, Charité--Campus Virchow Klinikum, Humboldt-University Berlin, Berlin, Germany.
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14
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Nüssler NC, Müller AR, Weidenbach H, Vergopoulos A, Platz KP, Volk HD, Neuhaus P, Nussler AK. IL-10 increases tissue injury after selective intestinal ischemia/reperfusion. Ann Surg 2003; 238:49-58. [PMID: 12832965 PMCID: PMC1422667 DOI: 10.1097/01.sla.0000074962.26074.d3] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE This study focused on the effect of immunoregulatory cytokines on tissue injury after intestinal ischemia/reperfusion (IR). Furthermore, the role of nitric oxide, heme oxygenase-1 (HO-1) and the transcription factor NF-kappaB/Rel in the disease process was evaluated.SUMMARY BACKGROUND DATA Oxidative stress and inflammatory gene products contribute to ischemia/reperfusion injury (IRI). However, expression of stress proteins such as the inducible nitric oxide synthase (NOS-2) and HO-1 might also provide protection against IRI. METHODS IR was achieved in Lewis rats by selective clamping of the superior mesenteric artery. IL-2 or IL-10 was administered intravenously before reperfusion. Animals were killed 1 hour, 4 hours, and 24 hours after reperfusion. Tissue destruction was assessed by hyaluronic acid (HA) and aminoaspartate-transaminase (AST) serum levels, whereas reduction of glutathione (GSH) tissue levels was used as a marker for oxidative stress. Furthermore, the activation of NF-kappaB/Rel and the expression of NOS-2 and HO-1 were analyzed.RESULTS IR resulted in tissue destruction and significantly reduced GSH tissue levels in the intestines and liver. In addition, NF-kappaB/Rel activation and increased NOS-2 and HO-1 mRNA expression were detected in both organs after IR. IL-2 administration resulted in clinical improvement of the animals and was associated with increased NF-kappaB/Rel activation and enhanced NOS-2 and HO-1 mRNA expression. In contrast, IL-10 resulted in increased tissue destruction in both organs and sustained reduction of GSH levels in the intestines. Furthermore, IL-10 administration failed to enhance NF-kappaB/Rel activity, NOS-2 mRNA, or HO-1 mRNA expression after IR. CONCLUSION IL-10 resulted in increased tissue damage after intestinal IR. This detrimental effect of IL-10 might have been the result of reduced NOS-2 and HO-1 mRNA expression. In contrast, the beneficial effect of IL-2 might have relied on increased HO-1 expression and NOS-2 activity. These controversial effects of IL-2 and IL-10 might have been mediated through transcriptional regulation of NOS-2 and HO-1 gene expression.
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Affiliation(s)
- Natascha C Nüssler
- Department of Surgery, Charité, Campus Virchow-Klinikum, Humboldt University of Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
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15
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Abstract
BACKGROUND Toxic megacolon is a life-threatening complication most commonly observed in patients with ulcerative colitis or Crohn's disease that is characterized by total or segmental nonobstructive colonic dilatation of at least 6 cm on plain abdominal films associated with systemic toxicity. CASE REPORT We report an unusual case of fulminant steroid-refractory ulcerative colitis complicated by toxic megacolon treated successfully with the immunosuppressant tacrolimus. CONCLUSION Tacrolimus administration induced clinical remission and bridged the time interval, until the standard immunosuppressant azathioprine could maintain clinical remission, thereby avoiding eminent emergency colectomy.
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Affiliation(s)
- Maria Pascu
- Division of Hepatology and Gastroenterology, Department of Internal Medicine, Campus Virchow, Charité Medical School, Augustenburger Platz 1, 13353 Berlin, Germany
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16
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Ulrich F, Steinmüller T, Settmacher U, Müller AR, Jonas S, Tullius SG, Neuhaus P. Therapy of Caroli's disease by orthotopic liver transplantation. Transplant Proc 2003; 34:2279-80. [PMID: 12270398 DOI: 10.1016/s0041-1345(02)03235-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- F Ulrich
- Department of General, Visceral and Transplantation Surgery, Charité, Virchow-Clinic, Humboldt-University, Berlin, Germany
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17
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Lange-Brock N, Berg T, Müller AR, Fliege H, Neuhaus P, Wiedenmann B, Klapp BF, Mönnikes H. [Acute liver failure following the use of ecstasy (MDMA)]. Z Gastroenterol 2003; 40:581-6. [PMID: 12297982 DOI: 10.1055/s-2002-33416] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The use of "ecstasy" (Methylenedioxymethamphetamine) as a recreational drug is increasing in europe since the 1980's. Aside intended psychological effects the use of ecstasy can be followed by symptoms of intoxication; complications include toxic hepatic damage up to acute hepatic failure. This case-report is about a 17-year old female patient who regularly used "ecstasy" over a six-month period. Two days after the last use of "ecstasy", she reported to her general practitioner with nausea, vomiting, abdominal pain and jaundice. Within 10 days the patient developed acute liver failure. With criteria for liver transplantation fulfilled she was listed for orthotopic liver transplantation of high urgency which was carried out only one day later. Histological examination of the explanted liver showed evidence for a toxic fulminant hepatitis. After transplantation the patient made a full recovery and was released from hospital on day 26 after transplantation. At the first control after six months the patient was in good physical and nutritional condition, serological parameters were normal and ultrasound examination of the transplanted liver was unremarkable. The ethiopathology of "ecstasy"-induced hepatotoxicity, which can occur dose-independently with a symptom-free period from days to weeks after ingestion is not yet fully understood. Possible mechanisms of hepatic damage include influence of MDMA on body temperature regulation, harmful effects of the substance or further components of the "ecstasy"-tablets on the liver cell or a genetic vulnerability of some individuals against amphetamines and amphetamine derivates. There are no parameters existing which could predict the course and severity of "ecstasy"-induced hepatopathy. Especially in young patients with symptoms of hepatic damage frequent controls of clinical status and relevant laboratory parameters are of great importance. Patient transfer to a specialised centre should follow as early as possible; at the latest, when coagulopathy occurs.
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Affiliation(s)
- N Lange-Brock
- Medizinische Klinik mit Schwerpunkt Psychosomatik und Psychotherapie des Universitätsklinikum Charité der Humboldt-Universität zu Berlin, Germany
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18
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Seehofer D, Rayes N, Tullius SG, Schmidt CA, Neumann UP, Radke C, Settmacher U, Müller AR, Steinmüller T, Neuhaus P. CMV hepatitis after liver transplantation: incidence, clinical course, and long-term follow-up. Liver Transpl 2002; 8:1138-46. [PMID: 12474153 DOI: 10.1053/jlts.2002.36732] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cytomegalovirus (CMV) hepatitis is described as the most frequent manifestation of CMV tissue invasive disease after liver transplantation. Its correlation with HLA-matching, hepatic artery thrombosis, and chronic rejection is still controversial. Risk factors, incidence, clinical course, and complications of CMV hepatitis were retrospectively analyzed in a 12-year series of 1,146 consecutive liver transplantations in 1,054 patients. All patients received only low-dose acyclovir but no gancyclovir prophylaxis. CMV infection was diagnosed by viral culture, pp65 antigenemia, or by polymerase chain reaction (PCR). CMV hepatitis was proven by liver biopsy. Treatment of CMV disease consisted of intravenous ganciclovir for a minimum of 14 days. Long-term follow-up of patients included monthly routine laboratory values and routine liver biopsies 1, 3 and 5 years after transplantation. CMV hepatitis was a rare event after liver transplantation, with a total incidence of 2.1% (24 cases). It was significantly more frequent in CMV seronegative (5.2%) than in seropositive recipients (0.7%). The leading indication in patients with CMV hepatitis was HCV cirrhosis (n = 8). The maximum number of pp65 positive white blood cells was 82 +/- 23 per 10,000 cells. Most courses manifested as isolated hepatitis; only 2 patients had disseminated disease. Nine of 24 patients had received OKT3 monoclonal antibodies because of steroid-resistant rejection before CMV hepatitis. In seronegative patients with CMV hepatitis, 71% revealed 1 or 2 HLA DR matches, in contrast to 32% in patients without CMV hepatitis. One-, 3-, and 5-year graft survival was 78%, 65%, and 59% in patients with CMV hepatitis compared with 88%, 81%, and 79% in patients without. Chronic rejection was observed in one patient, but already before onset of CMV hepatitis. Beneath D+R-constellation and OKT3 treatment as risk factors, HLA DR-matched grafts and HCV seem to favor manifestation of CMV hepatitis after liver transplantation. Long-term complications of CMV hepatitis were not observed, and especially no correlation with chronic rejection was found.
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Affiliation(s)
- Daniel Seehofer
- Department of General, Visceral, and Transplant Surgery, Charité Campus Virchow, Humboldt University of Berlin, Berlin, Germany.
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19
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Langrehr JM, Neumann UP, Lang M, Schmitz V, Menzel S, Müller AR, Steinmueller T, Neuhaus P. Impact of HLA compatibilities after liver transplantation. Transplant Proc 2002; 34:2940-1. [PMID: 12431666 DOI: 10.1016/s0041-1345(02)03497-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- J M Langrehr
- Klinik für Allgemein-, Viszeral-, und Transplantationschirurgie, Charité, Campus Virchow-Klinikum, Humboldt Universität zu Berlin, Berlin, Germany.
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20
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Abstract
Transjugular intrahepatic portosystemic shunts (TIPS) are indicated in patients with liver cirrhosis and portal hypertension for treatment of variceal bleeding or refractory ascites. Additionally implantation of stents may lead to stent dislocation or thrombosis in up to 20 % of cases. Detailed information about stent dislocation and its impact on subsequent orthotopic liver transplantation (OLT) is rare regarding the literature. We report on a patient suffering from ethyltoxic liver cirrhosis in which OLT was technically complicated by a thrombosed TIPS stent, dislocated in the portal vein. This stent was implanted prior to OLT due to refractory ascites and partial portal vein thrombosis. We conclude that TIPS stent insertion, especially in liver transplant candidates, should only be performed by radiologists in centers with expertise and experience.
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Affiliation(s)
- M Glanemann
- Klinik für Allgemein-, Visceral- und Transplantationschirurgie, Charité, Campus Virchow-Klinikum, Humboldt Universität zu Berlin, Germany.
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21
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Rayes N, Seehofer D, Müller AR, Hansen S, Bengmark S, Neuhaus P. [Influence of probiotics and fibre on the incidence of bacterial infections following major abdominal surgery - results of a prospective trial]. Z Gastroenterol 2002; 40:869-76. [PMID: 12436353 DOI: 10.1055/s-2002-35259] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Early enteral nutrition with fibre and probiotics has been effective in preventing bacterial translocation and is therefore expected to reduce the incidence of postoperative bacterial infections. PATIENTS AND METHODS In a prospective randomized trial including 172 patients following major abdominal surgery or liver transplantation, the incidence of bacterial infections was compared in patients receiving either a) conventional parenteral or enteral nutrition, b) enteral nutrition with fibre and lactobacillus plantarum 299 or c) enteral nutrition with fibre and heat inactivated lactobacilli (placebo). Liver transplant recipients were also treated with selective bowel decontamination (SBD). Routine laboratory parameters, nutritional parameters and the cellular immune status were measured preoperatively and on postoperative days 1, 5 and 10. RESULTS Patients were comparable regarding preoperative ASA-classification, Child-Pugh classification of cirrhosis, operative data and immunosuppression. The incidence of bacterial infections after liver, gastric oder pancreas resection was 31 % in the conventional group a) compared to 4 % in the lactobacillus-group b) and 13 % in the placebo-group c). In the analysis of 95 liver transplant recipients, 13 % group b)-patients developed infections compared to 48 % group a)-patients and 34 % group c)-patients. The difference between groups a) and b) was statistically significant in both cases. In addition, the duration of antibiotic therapy was significantly shorter in the lactobacillus-group. Cholangitis and pneumonia were the most frequent infections and enterococci the most frequently isolated bacteria. Fibre and lactobacilli were well tolerated in most cases. CONCLUSION Fibre and probiotics could lower the incidence of bacterial infections following major abdominal surgery in comparison to conventional nutrition with or without SBD. With this new concept, costs can be reduced by shortening the duration of antibiotic therapy and sparing SBD.
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Affiliation(s)
- N Rayes
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Charité Campus Virchow, Augustenburger Platz l, 13355 Berlin, Germany.
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22
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Berg T, Neuhaus R, Klein R, Leder K, Lobeck H, Bechstein WO, Müller AR, Wiedenmann B, Hopf U, Berg PA, Neuhaus P. Distinct enzyme profiles in patients with cryptogenic cirrhosis reflect heterogeneous causes with different outcomes after liver transplantation (OLT): a long-term documentation before and after OLT. Transplantation 2002; 74:792-8. [PMID: 12364857 DOI: 10.1097/00007890-200209270-00010] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Sound information is lacking about the clinical presentation of cryptogenic cirrhosis and its outcome after orthotopic liver transplantation (OLT). METHODS Among 856 patients who have been transplanted at our center, 40 patients had no evidence of any known etiologies and were therefore defined as suffering from cryptogenic cirrhosis. Their median follow-up period before OLT was 78 months (range, 1-264), and after OLT 97 months (range, 1-132). Laboratory and histological data were evaluated according to features being compatible either with a toxic, hepatitic, or cholestatic condition. RESULTS The clinical and histological findings differed specifically between these three groups. The toxic-like group (GGT 4-18 x upper limit of normal [ULN]) expressed significantly higher IgA levels, had histologically more often fatty liver changes, and risk factors for non-alcoholic steatohepatitis predominated (56% compared with 3% in the other groups, P=0.01). The hepatitic-like group (ALT 2-18 x ULN) showed histologically features of chronic hepatitis or hepatitic cirrhosis, and only among these patients a median International Autoimmune Hepatitis (IAH) score of 13 was found suggesting autoimmune hepatitis (AiH). In the cholestatic group (AP 2-8 x ULN) histology was compatible with a non-toxic inflammatory process but IAH score excluded AiH in all. After OLT, actuarial graft and patients survival was 90% at 5 years. Mild or moderate graft hepatitis occurred in 9 patients (23%) and was significantly associated with a pre-OLT IAH score >or= 10 (P =0.008). CONCLUSIONS This study provides arguments that cryptogenic cirrhosis is a heterogeneous disease in which autoimmune mechanisms might be predominately involved and being responsible for recurrence of chronic liver disease observed in some instances after OLT.
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Affiliation(s)
- Thomas Berg
- Medizinische Klinik mit Schwerpunkt Hepatologie und Gastroenterologie, Charité, Campus Virchow-Klinikum, Humboldt-Universität zu Berlin, Germany.
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23
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Seehofer D, Rayes N, Steinmüller T, Schmidt CA, Settmacher U, Müller AR, Neuhaus P. Minimal impact of CMV infection on long-term survival after liver transplantation. Transplant Proc 2002; 34:2272-3. [PMID: 12270394 DOI: 10.1016/s0041-1345(02)03231-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- D Seehofer
- Department of General-, Visceral- and Transplant Surgery, Charité Campus Virchow, Humboldt University of Berlin, Berlin, Germany.
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Seehofer D, Rayes N, Steinmüller T, Neuhaus R, Berg T, Müller AR, Neuhaus P. Liver transplantation in hepatitis B patients with preoperative resistance formation during lamivudine treatment. Transplant Proc 2002; 34:2274-5. [PMID: 12270395 DOI: 10.1016/s0041-1345(02)03232-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- D Seehofer
- Department of General-Surgery, Charité Campus Virchow, Humboldt University of Berlin, Berlin, Germany
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25
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Seehofer D, Rayes N, Steinmüller T, Müller AR, Jonas S, Settmacher U, Neuhaus R, Berg T, Neuhaus P. Combination prophylaxis with Hepatitis B immunoglobulin and lamivudine after liver transplantation minimizes HBV recurrence rates unless evolution of pretransplant lamivudine resistance. Z Gastroenterol 2002; 40:795-9. [PMID: 12215948 DOI: 10.1055/s-2002-33874] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Survival rates of hepatitis B patients after liver transplantation improved significantly by introduction of passive immunoprophylaxis. Due to viral escape mutations recurrence still occurs, but recently a combination prophylaxis with hepatitis B immunoglobuline plus lamivudine is evaluated in transplant centers in terms of a further reduction of recurrence rates. PATIENTS AND METHODS Between 1996 and 2000 a postoperative combination prophylaxis with HBIg and lamivudine was initiated in 44 HBsAg positive liver transplant recipients. In total 14 patients were HBV-DNA negative and 30 were HBV-DNA positive at the time of evaluation. In 22 HBV-DNA positive patients a pre-operative lamivudine treatment (150 mg/die) was started. Five of them developed pre-transplant lamivudine resistance with high viral replication (mean HBV-DNA prior to transplantation 728 +/- 219 pg/ml). In all patients passive immunoprophylaxis was started in the anhepatic phase with application of 10.000 units hepatitis B immunoglobuline. It was continued after seroconversion to HBsAg negativity with an aimed titer of more than 100 U/l and only stopped in case of HBV recurrence. Lamivudine was also continued indefinitely after liver transplantation. RESULTS Overall recurrence rate in the 44 patients, including retransplantations and patients with pretransplant lamivudine resistance, was 11.5 % under combination prophylaxis. Recurrence was seen only in one of 39 patients (2.6 %) without preoperative lamivudine resistance, in contrast 4 out of 5 patients (80 %) with pre-existing lamivudine resistance suffered from early hepatitis B recurrence. The single patient without preoperative lamivudine resistance, who developed recurrence was pre-transplant HBV-DNA negative without lamivudine treatment, but a postoperative seroconversion to negative HBsAg could not be achieved. The overall 3 year patient survival rate was 91 % in the study population. One patient, who was retransplanted with preoperative lamivudine resistance, died 4.5 months after retransplantation due to hepatitis B recurrence and sepsis, three other patients died for reasons not related to hepatitis B recurrence. Combination prophylaxis was well tolerated in all patients and no severe side effects were observed. CONCLUSION Combination prophylaxis with hepatitis B immunoglobulin and lamivudine is safe and highly effective in prevention of HBV recurrence after liver transplantation, even in case of positive viral replication. In accordance with the results of other centers it should therefore be the standard regimen. However it fails in the majority of patients with preoperative evolution of YMDD mutations, in which the optimal management has to be determined yet. To minimize preoperative resistance formation universal preoperative antiviral treatment of HBV-DNA positive patients should be replaced by individualized indication for preoperative treatment.
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Affiliation(s)
- D Seehofer
- Department of General-, Visceral- and Transplant-Surgery, Charité Campus Virchow, Humboldt University of Berlin, Germany.
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Ulrich F, Steinmüller T, Lang M, Settmacher U, Müller AR, Jonas S, Tullius SG, Neuhaus P. Liver transplantation in patients with advanced Budd-Chiari Syndrome. Transplant Proc 2002; 34:2278. [PMID: 12270397 DOI: 10.1016/s0041-1345(02)03234-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- F Ulrich
- Department of General, Visceral and Transplantation Surgery, Charite, Virchow-Clinic, Humboldt-University, Berlin, Germany
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Oppert M, Schneider U, Bocksch W, Izmir F, Müller AR, Settmacher U, Kampf D, Neuhaus P, Frei U, Kahl A. Improvement of left ventricular function and arterial blood pressure 1 year after simultaneous pancreas kidney transplantation. Transplant Proc 2002; 34:2251-2. [PMID: 12270386 DOI: 10.1016/s0041-1345(02)03223-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- M Oppert
- Dept. of Nephrology, Charité, Virchow-Clinic, Humboldt University, Berlin, Germany
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Langrehr JM, Neumann UP, Lang M, Müller AR, Jonas S, Settmacher U, Steinmüller T, Neuhaus P. First results from a prospective randomized trial comparing steroid-free induction therapy with tacrolimus and MMF versus tacrolimus and steroids in patients after liver transplantation for HCV. Transplant Proc 2002; 34:1565-6. [PMID: 12176487 DOI: 10.1016/s0041-1345(02)03024-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- J M Langrehr
- Department of Surgery, Charité, Virchow-Klinikum, Humboldt University, Augustenburger Platz 1, 13353 Berlin, Germany
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Jonas S, Guckelberger O, Müller AR, Langrehr JM, Settmacher U, Tullius SG, Steinmüller T, Neuhaus P. Cyclosporine-based quadruple induction therapy versus tacrolimus-based dual immunosuppression after liver transplantation: ten-year follow-up. Transplant Proc 2002; 34:1504-6. [PMID: 12176459 DOI: 10.1016/s0041-1345(02)02949-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- S Jonas
- Department of General, Visceral and Transplantation Surgery, Charité-Campus Virchow Klinikum, Humboldt University Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
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Steinmüller T, Seehofer D, Rayes N, Müller AR, Settmacher U, Jonas S, Neuhaus R, Berg T, Hopf U, Neuhaus P. Increasing applicability of liver transplantation for patients with hepatitis B-related liver disease. Hepatology 2002; 35:1528-35. [PMID: 12029640 DOI: 10.1053/jhep.2002.33681] [Citation(s) in RCA: 168] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Liver transplantation in patients with hepatitis B has been under discussion for 20 years because of inferior results without reinfection prophylaxis; therefore, we analyzed our overall experience with liver transplantation in hepatitis B patients with immunoprophylaxis, particularly the influence of the available antiviral treatment in different periods. From 1988 to 2000, 228 liver transplants in 206 hepatitis B patients were performed. Indications were acute liver failure (10%), hepatitis B virus (HBV) cirrhosis alone (67%) or with hepatitis D virus (HDV) (13%), or hepatitis C virus (HCV) coinfection (7%). All patients received long-term immunoprophylaxis (anti-HBs > 100 U/L). HBV DNA-positive patients were treated before and after surgery with famciclovir or lamivudine since 1993 and 1996, respectively. Since 1993, antivirals also were used for HBV reinfection. The 1-, 5-, and 10-year patient survival rates were 91%, 81%, and 73%. In patients with hepatocellular carcinoma (HCC) (60% 5-year survival, P <.01) or HBV reinfection (69% 5-year survival, P <.01) survival was significantly impaired. Those with HDV or HCV coinfection had a slightly better survival than with HBV monoinfection (P >.05, not significant). Preoperative positive HBV DNA (hybridization-assay) test results were associated with a slightly impaired patient survival (78% 5-year survival, P >.05, not significant versus DNA-negative). Preoperative positive hepatitis B e antigen (HBeAg) predicted significantly worse survival (P <.05 versus negative HBeAg). Graft loss caused by reinfection was most frequent before the availability of antiviral drugs. Two-year patient survival increased from 85% in era I (1988-1993) to 94% in era III (1997-2000, P <.05). The 2-year recurrence rates in these 2 periods were 42% and 8% (P <.05). In conclusion, excellent long-term results can be achieved in hepatitis B patients after liver transplantation with modern strategies, and survival rates are similar to other indications. Based on our experience, hepatitis B patients, including those with active viral replication, should not be excluded from liver transplantation.
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Affiliation(s)
- Thomas Steinmüller
- Department of General, Visceral, and Transplant Surgery, Charité Campus Virchow, Humboldt University of Berlin, Berlin, Germany.
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Steinmüller T, Pascher A, Sauer IM, Theruvath T, Müller AR, Settmacher U, Neuhaus P. [Living donor liver transplantation of the right liver lobe between adults]. Dtsch Med Wochenschr 2002; 127:1067-71. [PMID: 12016553 DOI: 10.1055/s-2002-30123] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND AND OBJECTIVE Adult living donor liver transplantation has been established in an increasing number of transplant centres during the last few years. Donor safety and risks are important criteria influencing the further development. We report our experience with 43 adult-to-adult right lobe living donor liver transplantations. METHODS 43 patients (mean age: 49,8 +/- 16,0 years; f:m = 14:29) with end-stage liver disease received a right lobe liver graft from an adult living donor (mean age: 42,4 +/- 13,4 years; f:m = 27:16) between December 1999 and December 2001. An approval by the local ethics committee was obtained prior to the start of the programme and each donation. RESULTS None of the donors experienced fatal or long-term complications. The rate of surgical complications in donors (biliary leakage, bleeding) was 9 %. Actuarial recipient survival was 93 % after three months and 88 % after one year. Five patients had to be re-transplanted. Thus the actuarial 1-year graft survival was 79 %. Biliary complications occurred in 14 % of all recipients. CONCLUSION According to our experience, living donor liver transplantation of the right hepatic lobe is a safe and effective procedure. Especially for patients in acute and chronic liver failure, who otherwise would have died on the waiting list, this approach offers a life-saving option.
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Affiliation(s)
- T Steinmüller
- Klinik für Allgemein, Viszeral und Transplantationschirurgie, Charité, Campus Virchow, Medizinische Fakultät der Humboldt Universität zu Berlin, Germany.
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Seehofer D, Rayes N, Steinmüller T, Müller AR, Settmacher U, Neuhaus R, Radke C, Berg T, Hopf U, Neuhaus P. Occurrence and clinical outcome of lamivudine-resistant hepatitis B infection after liver transplantation. Liver Transpl 2001; 7:976-82. [PMID: 11699034 DOI: 10.1053/jlts.2001.28442] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Lamivudine treatment of hepatitis B after orthotopic liver transplantation (OLT) is often accompanied by fast viral-resistance formation. Although no clinical data are available, in vitro data indicate that lamivudine-resistant reinfection has a mild course because of defective viral replication. Between 1996 and 1999, a total of 34 patients were treated with lamivudine because of hepatitis B recurrence after OLT. All patients developed reinfection despite long-term passive immunoprophylaxis with hepatitis B immunoglobulin, diagnosed by positive hepatitis B surface antigen and positive hepatitis B virus (HBV) DNA. Before treatment with lamivudine, 21 of these patients underwent a course of famciclovir and developed resistance. Monthly laboratory tests and sequential liver biopsies were performed during the follow-up period. Nineteen of 34 patients (56%) developed lamivudine resistance during the follow-up period of 12 to 49 months. One- and 3-year graft survival rates after the diagnosis of lamivudine resistance were 89% and 66%, respectively. In most cases, lamivudine resistance was associated with high viral replication (3,012 +/- 574 pg/mL 1 month after the diagnosis of lamivudine resistance); however, liver enzyme levels were only moderately elevated (alanine aminotransferase [ALT], 45 +/- 16 U/L). Only 3 patients (15%) showed a rapid increase in ALT level to more than 500 U/L within 3 months after resistance developed. All other patients had mildly elevated liver enzyme levels during the first 6 to 8 months after lamivudine resistance. In the later course, liver enzyme levels increased in most patients. Fourteen patients with elevated transaminase levels were switched to lamivudine plus interferon alfa (n = 8) or lamivudine plus famciclovir therapy (n = 6). This combination was successful in most cases, decreasing HBV DNA and liver enzyme levels. Four patients with lamivudine resistance died during follow-up, only 1 patient because of HBV reinfection. In addition, 2 patients underwent retransplantation because of hepatitis B cirrhosis of the first graft. Compared with historic courses of wild-type recurrence, lamivudine-resistant reinfection is characterized by a milder clinical course. Fulminant cases were not observed; however, in three cases, chronic liver failure developed. The combination of different antivirals diminished viral replication after lamivudine resistance. In the future, new antiviral agents, such as adefovir, might further expand therapeutic options.
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Affiliation(s)
- D Seehofer
- Department of General, Visceral, and Transplant Surgery, Campus Virchow, Humboldt University of Berlin, Germany.
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Seehofer D, Rayes N, Naumann U, Neuhaus R, Müller AR, Tullius SG, Berg T, Steinmüller T, Bechstein WO, Neuhaus P. Preoperative antiviral treatment and postoperative prophylaxis in HBV-DNA positive patients undergoing liver transplantation. Transplantation 2001; 72:1381-5. [PMID: 11685107 DOI: 10.1097/00007890-200110270-00008] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Despite passive immunoprophylaxis a significant number of patients, especially if hepatitis B virus (HBV) DNA is positive prior to transplantation, develop HBV recurrence. This number might be reduced by lowering viral replication pretransplant with antiviral agents and by postoperative combination of antiviral agents and passive immunoprophylaxis. PATIENTS AND METHODS A total of 74 HBV-DNA positive patients who underwent liver transplantation between 9/88 and 4/00 were analyzed retrospectively. Before lamivudine or famciclovir were available, in total 40 patients did not receive any preoperative antiviral therapy. Since 11/93, 17 patients were treated with famciclovir 1500 mg daily, after 4/96 17 patients with lamivudine 150 mg daily prior liver transplantation. Posttransplant all patients received passive immunoprophylaxis aiming at a titer of more than 100 U/liter. In the 34 patients with preoperative antiviral therapy an additional prophylaxis with the respective antiviral agent was applied. RESULTS Under preoperative famciclovir and lamivudine 30 and 71% of patients became HBV-DNA negative, respectively. Actuarial reinfection rate 2 years after liver transplantation was 48% without antiviral prophylaxis, which was not statistically different from 55% under perioperative famciclovir therapy. In contrast only 18% developed HBV recurrence under perioperative lamivudine treatment. During both antiviral regimens neither pre nor posttransplant severe side effects were observed. CONCLUSION Perioperative application of famciclovir is not recommendable, whereas lamivudine seems to lower recurrence rates significantly. Whether the observed effect is due to pre- or postoperative application remains to be addressed in further studies. In addition the long-term course has to be awaited.
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Affiliation(s)
- D Seehofer
- Department of Visceral and Transplant Surgery, Charité Campus Virchow, Augustenburger Platz 1, D-13353 Berlin, Germany
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Rayes N, Seehofer D, Schmidt CA, Oettle H, Müller AR, Steinmüller T, Settmacher U, Bechstein WO, Neuhaus P. Prospective randomized trial to assess the value of preemptive oral therapy for CMV infection following liver transplantation. Transplantation 2001; 72:881-5. [PMID: 11571454 DOI: 10.1097/00007890-200109150-00024] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND With the development of sensitive tests to detect cytomegalovirus (CMV) viremia, preemptive approaches become a reasonable alternative to general CMV prophylaxis. We performed a randomized trial comparing pp65-antigenemia guided preemptive therapy using oral ganciclovir with symptom-triggered intravenous ganciclovir treatment. METHODS Eighty-eight of 372 liver transplant recipients developed antigenemia early after orthotopic liver transplantation. Twenty-eight symptomatic patients with antigenemia were excluded from randomization and treated with intravenous ganciclovir. Sixty pp65-antigen-positive asymptomatic patients were randomized to receive either oral ganciclovir 3x1 g/day for 14 days (group 1) or no preemptive treatment (group 2). Patients that developed CMV disease were treated with intravenous ganciclovir 2x5 mg/kg body weight for 14 days. The high-risk (Donor+/Recipient-) patients were equally distributed in the two study groups. RESULTS Three of 30 (10%) patients on oral ganciclovir developed mild to moderate CMV disease compared with 6/30 (20%) patients in the control group. In the Donor+/Recipient- patients, the incidence of CMV disease was 1/6 and 3/7. All disease episodes resolved after intravenous treatment. The 1- and 3-year patient and organ survival was the same in the study groups and in the patients with or without CMV infection. No deaths related to CMV occurred. CONCLUSIONS The positive predictive value of pp65-antigenemia for the development of CMV disease was very low, and, in 28/88 patients (32%), antigenemia did not precede symptoms. Therefore, pp65-antigenemia is of limited value in deciding on the timing and need for ganciclovir therapy after liver transplantation.
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Affiliation(s)
- N Rayes
- Department of Surgery, Charité Campus Virchow, Augustenburger Platz 1, 13355 Berlin, Germany
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Glanemann M, Kaisers U, Langrehr JM, Schenk R, Stange BJ, Müller AR, Bechstein WO, Falke K, Neuhaus P. Incidence and indications for reintubation during postoperative care following orthotopic liver transplantation. J Clin Anesth 2001; 13:377-82. [PMID: 11498321 DOI: 10.1016/s0952-8180(01)00290-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
STUDY OBJECTIVE To analyze the incidence and indications for reintubation during postoperative care following orthotopic liver transplantation (OLT). DESIGN Retrospective chart review. SETTING Large metropolitan teaching hospital. PATIENTS 546 adult liver transplant recipients. MEASUREMENTS AND MAIN RESULTS The medical charts of 546 patients who underwent OLT at our institution between January 1992 and September 1996 were reviewed for the incidence and indications of reintubation throughout primary hospitalization. Eighty-one of 546 patients (14.8%) required one or more episodes of reintubation after OLT. In the majority of cases, reintubation was performed for pulmonary complications (44.6%), followed by cerebral (19.1%) and surgical (14.5%) complications. Cardiac (9.1%) and peripheral neurologic (2.7%) complications were less frequent reasons for reintubation. Overall patient survival, according to the Kaplan-Meier estimates, was 89.9%, 87.5%, 86.5%, and 82.2% after 1, 2, 3, and 5 years, respectively. In patients with one or more episodes of reintubation, overall survival decreased to 62.5% after 1, 2, and 3 years, and to 56.4% after 5 years (p < 0.001). CONCLUSIONS The main indications for reintubation after OLT were pulmonary, cerebral, and surgical complications. These reintubation events had a considerable influence on the patient's postoperative recovery, and were associated with a significantly higher rate of mortality, than for OLT patients who did not undo reintubation.
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Affiliation(s)
- M Glanemann
- Department of General-, Visceral- & Transplantation Surgery, Charité, Campus Virchow Klinikum, Humboldt University Berlin, Germany.
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Seehofer D, Rayes N, Neuhaus R, Berg T, Müller AR, Bechstein WO, Neuhaus P. Antiviral combination therapy for lamivudine-resistant hepatitis B reinfection after liver transplantation. Transpl Int 2001; 13 Suppl 1:S359-62. [PMID: 11112032 DOI: 10.1007/s001470050361] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Development of resistance is a major issue in antiviral treatment of hepatitis B reinfection after liver transplantation. Antiviral combination therapy is discussed for therapy or prevention of this breakthrough of viral replication. Eight patients were enrolled into this retrospective analysis after liver transplantation for chronic hepatitis B infection. All had reinfection of the graft and breakthrough of HBV during consecutive famciclovir and lamivudine monotherapy. Subsequently a combination therapy with lamivudine and interferon-alpha 2a (group I, n = 4) or lamivudine and famciclovir (group II, n = 4) was initiated. Combination therapy was started 61 months (group I) and 25 months (group II) after liver transplantation. It markedly reduced the viral replication rate in all patients despite lamivudine resistance. In group I three of four patients and in group II two of four patients became HBV-DNA negative. Two long-term responders were observed in group I, and none in group II. No patient became HBsAg negative or lost HbeAg. Pretreatment elevated ALT and AST levels were significantly reduced. No severe complications, and especially no rejection episodes, occurred. Lamivudine in combination with other antiviral agents, especially interferon-alpha, might be a therapeutic option for hepatitis B reinfection after liver transplantation. Suppression of virus replication to the point of undetectable values is possible even in patients with lamivudine-resistant virus mutations.
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Affiliation(s)
- D Seehofer
- Department of General-Visceral and Transplant Surgery, Humboldt University of Berlin, Germany
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Jonas S, Guckelberger O, Tullius SG, Steinmüller T, Müller AR, Grauhan O, Langrehr JM, Bechstein WO, Neuhaus P. Corticosteroid-free therapy after tacrolimus-based dual immunosuppression versus cyclosporine-based quadruple-induction therapy. Transplant Proc 2001; 33:2232-3. [PMID: 11377511 DOI: 10.1016/s0041-1345(01)02065-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- S Jonas
- Department of General, Visceral and Transplantation Surgery, Charité-Virchow Klinikum, Humboldt University Berlin, Berlin, Germany
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Seehofer D, Rayes N, Berg T, Neuhaus R, Müller AR, Hopf U, Bechstein WO, Neuhaus P. Lamivudine as first- and second-line treatment of hepatitis B infection after liver transplantation. Transpl Int 2001; 13:290-6. [PMID: 10959482 DOI: 10.1007/s001470050704] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Lamivudine and famciclovir have expanded therapeutical options for HBV infection after liver transplantation. First studies confirm good antiviral effects of both, but at present the major problem seems to be a rapid resistance formation in immunosuppressed patients. Thirty-four adult patients with HBV recurrence despite passive immunoprophylaxis and seven with de novo infection after orthotopic liver transplantation (OLT) were treated with 100-150 mg lamivudine daily. Patients were either treated directly after infection (n = 14) or after breakthrough of viral replication during an initial famciclovir therapy (n = 27). All patients except two responded to treatment with a reduction of serum HBV-DNA of over 50%. Thirty-one patients (76%) turned HBV-DNA-negative during lamivudine therapy. Viral breakthrough was observed in 14 of these patients after 4-13 months of treatment. A total of 17 patients (40%) remained HBV-DNA-negative for more than 12 months. Only nine patients eliminated HBsAg, of which four had and an HDV coinfection. None of the HBeAg-positive patients converted to anti-HBe. Most patients showed a prompt and significant reduction of aspartate aminotransferase (ALAT) levels. No severe complications occurred. Therefore, a safe and effective therapy of HBV infection after transplantation is possible with lamivudine. Viral replication is suppressed even in patients who revealed breakthrough during famciclovir therapy. Resistance formation as a major drawback occurred in one third of the patients within the first year of treatment.
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Affiliation(s)
- D Seehofer
- Department of General-, Visceral- and Transplant Surgery, Humboldt University of Berlin, Germany
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Sauer IM, Pascher A, Steinmüller T, Settmacher U, Müller AR, Bechstein WO, Neuhaus P. Split liver and living donation liver transplantation: the Berlin experience. Transplant Proc 2001; 33:1459-60. [PMID: 11267372 DOI: 10.1016/s0041-1345(00)02551-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- I M Sauer
- Klinik für Allgemein, Viszeral und Transplantationschirurgie, Charité-Campus Virchow Klinikum Medizinische Fakultät der Humboldt-Universität zu Berlin, Berlin, Germany
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Rayes N, Seehofer D, Schmidt CA, Müller AR, Steinmüller T, Bechstein WO, Neuhaus P. Is preemptive therapy for CMV infection following liver transplantation superior to symptom-triggered treatment? Transplant Proc 2001; 33:1804. [PMID: 11267520 DOI: 10.1016/s0041-1345(00)02688-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- N Rayes
- Department of Surgery, Charite Campus Virchow, Berlin, Germany
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Langrehr JM, Lohmann R, Guckelberger O, Müller AR, Raakow R, Nüssler NC, Klupp J, Pfitzmann R, Jonas S, Settmacher U, Steinmüller T, Neuhaus P. IL-2 receptor antibody induction increases the risk for chronic rejection after liver transplantation. Transplant Proc 2001; 33:1433-4. [PMID: 11267360 DOI: 10.1016/s0041-1345(00)02541-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- J M Langrehr
- Department of Surgery, Charité Campus Virchow-Klinikum, Humboldt University Berlin, Berlin, Germany
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Seehofer D, Rayes N, Bechstein WO, Naumann U, Neuhaus R, Berg T, Hopf U, Langrehr JM, Steinmüller T, Platz KP, Müller AR, Neuhaus P. [Therapy of recurrent hepatitis B infection after liver transplantation. A retrospective analysis of 200 liver transplantations based on hepatitis B associated liver diseases]. Z Gastroenterol 2000; 38:773-83. [PMID: 11072673 DOI: 10.1055/s-2000-7528] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Before introduction of passive immunoprophylaxis and new antiviral nucleoside analogues the course of hepatitis B recurrence after liver transplantation could hardly be influenced. The result was a inferior graft survival. In the present retrospective analysis of the efficacy of hepatitis B therapy after liver transplantation was analysed retrospectively. PATIENTS AND METHODS Between 1988 and 1998 in total 179 patients were transplanted due to hepatitis B related liver failure at our centre. All patients received passive immunoprophylaxis with hepatitis B immunoglobulin. In case of reinfection after 1993 an antiviral therapy with famciclovir 1500 mg daily was initiated (n = 26), since 1996 lamivudine (100-150 mg daily) was used (n = 12). In case of viral breakthrough under famciclovir treatment or prophylaxis therapy was switched to lamivudine (n = 22). In case of ineffectiveness of lamivudine an antiviral combination therapy with lamivudine and interferon (n = 4) or lamivudine and famciclovir (n = 4) was initiated. Before availability of antiviral agents or in case of viral breakthrough in total 12 patients were retransplanted due to acute or chronic reinfection. RESULTS With passive immunoprophylaxis reinfection rate was 33%, 43% and 44% after 1, 3 and 5 years respectively. Without antiviral treatment 52% of patients died within the first year after reinfection. Antiviral therapy with lamivudine or famciclovir improved the one year survival after reinfection to 79%. Suppression of viral replication was more effective with lamivudine. Under lamivudine 26 patients (76%) became HBV-DNA negative, 9 patients HBsAg negative (26%). In contrast no patient became HBsAg negative during famciclovir therapy. Lamivudine was effective also after famciclovir breakthrough in 94% of patients. In case of lamivudine resistant reinfection viral replication could be suppressed with an antiviral combination therapy up to negative HBV-DNA in the hybridization assay. Severe side effects were not observed during any of the antiviral therapies. The graft survival after retransplantation for hepatitis B reinfection was 42% and 25% after one and 3 years. CONCLUSION Whereas it is generally accepted, that passive immunoprophylaxis lowers the reinfection rate it could be shown in the present study, that antiviral treatment lowers mortality of hepatitis B reinfection. The major problem of lamivudine and famciclovir is viral resistance formation. In this case an antiviral combination therapy might be useful, whereas retransplantation for hepatitis B reinfection should be considered carefully due to inferior graft survival rates.
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Affiliation(s)
- D Seehofer
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Humboldt-Universität zu Berlin.
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Nüssler NC, O'Brien J, Stange B, Platz KP, Neuhaus P, Müller AR. IL-2 promotes the subset restoration of intraepithelial lymphocytes after ischemia/reperfusion injury. Transplant Proc 2000; 32:1305-6. [PMID: 10995959 DOI: 10.1016/s0041-1345(00)01237-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- N C Nüssler
- Department of Surgery, Charité Campus Virchow-Klinikum, Humboldt University Berlin, Berlin, Germany
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Gebke E, Müller AR, Pehl U, Gerstberger R. Astrocytes in sensory circumventricular organs of the rat brain express functional binding sites for endothelin. Neuroscience 2000; 97:371-81. [PMID: 10799769 DOI: 10.1016/s0306-4522(00)00051-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Sensory circumventricular organs bordering the anterior third cerebral ventricle, the subfornical organ and the organum vasculosum laminae terminalis, lack blood-brain barrier characteristics and are therefore accessible to circulating peptides like endothelins. Astrocytes of the rat subfornical organ and organum vasculosum laminae terminalis additionally showed immunocytochemical localization of endothelin-1/endothelin-3-like peptides, possibly acting as circumventricular organ-intrinsic modulators. Employing [125I]endothelin-1 as radioligand, quantitative autoradiography demonstrated specific binding sites throughout the rat organum vasculosum laminae terminalis and subfornical organ, and competitive displacement studies revealed expression of both ET(A) and ET(B) receptor subtypes for either circumventricular organ. ET(B) receptor binding prevailed for the whole brain and ET(A) receptors could be labelled in the peripheral vascular system. To characterize endothelin-specific receptors in astrocytes of both circumventricular organs, alterations in the intracellular calcium concentration due to endothelin-1/endothelin-3 stimulation were studied in primary culture of subfornical organ and organum vasculosum laminae terminalis cells obtained from early postnatal rat pups. Endothelin-1 and endothelin-3 induced Ca(2+) transients in 9-13% of either subfornical organ or organum vasculosum laminae terminalis astrocytes, respectively, and some glial cells (subfornical organ: 2%, organum vasculosum laminae terminalis: 5%) responded to both endothelin analogues. The antagonistic action of BQ123 specific for ET(A) receptors (74% of all astrocytes tested), and the pronounced responsiveness to the ET(B) receptor agonist [4Ala]ET-1 (subfornical organ: 27%, organum vasculosum laminae terminalis: 35%) demonstrated glial expression of both endothelin receptor subtypes. Agonist-induced elevations in the intracellular calcium concentration proved to be independent of extracellular Ca(2+). In summary, the results indicate that endothelin(s) interact(s) with circumventricular organ astrocytes. Competitive receptor binding techniques using brain tissue sections as well as a fura-2 loaded primary cell culture system of the subfornical organ and organum vasculosum laminae terminalis demonstrate glial expression of functional ET(A) and ET(B) receptors, with calcium as intracellular messenger emerging primarily from intracellular stores. Endothelin(s) of both circulating and circumventricular organ-intrinsic origin may afferently transfer information important for cardiovascular homeostasis to circumventricular organs serving as "windows to the brain".
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Affiliation(s)
- E Gebke
- Max-Planck-Institute for Physiological and Clinical Research, W.G. Kerckhoff-Institute, Parkstrasse 1, D-61231, Bad Nauheim, Germany
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Sauer IM, Kahl A, Müller AR, Neuhaus P, Bechstein WO. An unusual case of early pancreas graft loss. Ann Transplant 2000; 4:52-4. [PMID: 10850594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
Vascular thrombosis is the leading cause of nonimmunologic, technical graft loss following pancreas transplantation. An unusual case of early pancreas graft loss due to dissection of an atherosclerotic plaque -- presumably caused by clamping during implantation -- is described.
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Affiliation(s)
- I M Sauer
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Charité - Campus Virchow-Klinikum, Medizinische Fakultät der Humboldt-Universität zu Berlin, Germany
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Seehofer D, Rayes N, Berg T, Neuhaus R, Müller AR, Hopf U, Bechstein WO, Neuhaus P. Lamivudine as first- and second-line treatment of hepatitis B infection after liver transplantation. Transpl Int 2000. [DOI: 10.1111/j.1432-2277.2000.tb01084.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Seehofer D, Rayes N, Berg T, Neuhaus R, Hopf U, Müller AR, Bechstein WO, Neuhaus P. Additional interferon alpha for lamivudine resistant hepatitis B infection after liver transplantation: a preliminary report. Transplantation 2000; 69:1739-42. [PMID: 10836394 DOI: 10.1097/00007890-200004270-00039] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Resistance formation is a major problem in antiviral treatment of hepatitis B recurrence after liver transplantation. One possible therapeutic approach is an antiviral combination therapy with synergistic drugs. Four patients who were transplanted for chronic hepatitis B were analyzed retrospectively. All patients had reinfection of the graft and breakthrough of hepatitis B virus (HBV) during consecutive famciclovir and lamivudine monotherapy. Subsequently a combination therapy of lamivudine and interferon alpha 2a (3 times 3 million units weekly) was initiated. Addition of interferon markedly reduced viral replication rate in all patients. Three patients became HBV-DNA negative despite lamivudine resistance, but only two had a sustained response. No patient seroconverted to anti-HBe or lost HBsAg, but all patients showed a normalization of alanine aminotransferase and aspartate aminotransferase levels. No severe complications, and especially no rejection episodes occurred. Therefore lamivudine combined with interferon might be used for the therapy of hepatitis B reinfection after liver transplantation.
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Affiliation(s)
- D Seehofer
- Department of Visceral and Transplant Surgery, Humboldt University of Berlin, Germany
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48
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Neumann UP, Kaisers U, Langrehr JM, Glanemann M, Müller AR, Lang M, Jörres A, Settmacher U, Bechstein WO, Neuhaus P. Administration of prostacyclin after liver transplantation: a placebo controlled randomized trial. Clin Transplant 2000; 14:70-4. [PMID: 10693639 DOI: 10.1034/j.1399-0012.2000.140113.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The shortage of suitable organs for liver grafts is responsible for the use of marginal donors for liver transplantation (OLT). If these liver grafts function poorly initially after OLT, a supportive therapy is necessary. The purpose of this study was to evaluate the effects of prostacyclin (PGI2) on postoperative liver graft function after OLT. A total of 30 adult recipients of primary OLT were randomized to either receive PGI2 (4 ng/kg per min body weight, n = 15) or a placebo for 6 d. To evaluate regional splanchnic oxygenation a fiberoptic pulmonary-artery catheter was inserted into a hepatic vein and the difference between mixed venous oxygen content and hepatic venous oxygen content was determined (deltaO2). Measurements were performed directly after transplantation and at 6, 12, 24 and 48 h postoperatively. A significant correlation between deltaO2 and the level of transaminases (ALT/AST) was observed 24 and 48 h after transplantation (p < 0.05). PGI2 treatment induced a significant decrease in deltaO2 after 24 and 48 h after reperfusion (p < 0.05). Peak AST levels tended to be lower in the PGI2 treatment group (418 +/- 99 vs. 638 +/- 156 U/L, p < 0.1). These results suggest that administration of PGI2 after OLT improves hepatic-splanchnic oxygenation and may thereby reduce reperfusion injury after OLT.
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Affiliation(s)
- U P Neumann
- Klinik für Vizeral und Transplantationschirurgie, Humboldt-Universität zu Berlin, Germany.
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Rayes N, Seehofer D, Bechstein WO, Müller AR, Berg T, Neuhaus R, Neuhaus P. Long-term results of famciclovir for recurrent or de novo hepatitis B virus infection after liver transplantation. Clin Transplant 1999; 13:447-52. [PMID: 10617232 DOI: 10.1034/j.1399-0012.1999.130602.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Since the introduction of famciclovir in the treatment of hepatitis B virus (HBV) infection after liver transplantation, promising results have been published. In this study, the long-term efficacy and safety of famciclovir were assessed. Twenty-four patients with recurrent hepatitis B and 6 patients with de novo infection after liver transplantation were enrolled in an open prospective trial. Patients received oral famciclovir, 500 mg three times daily. Serum HBV-DNA, viral serology, and liver enzymes were measured sequentially; liver histology was taken before and during treatment in 12 patients. In the reinfected patients, 17 patients initially responded well to treatment, with a mean decrease of HBV-DNA of 82%, 5 patients became HBV-DNA negative. The drug was effective for 1-51 months (mean 16 months), then viral replication increased again in 13 out of 17 patients. One patient did not respond to treatment. Six out of 24 patients already had severe cirrhosis at the time of enrollment and died shortly afterwards, due to the HBV infection. The 6 patients with de novo infection all had a decline of HBV-DNA for 2-42 months (mean 14 months); 1 patient converted to HBV-DNA negative. Five out of 6 patients experienced a viral breakthrough later on. No severe side-effects were observed. Therefore, famciclovir is effective in certain HBV-infected patients after orthotopic liver transplantation (OLT), but in the long term, most of the patients relapse.
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Affiliation(s)
- N Rayes
- Department of Surgery, Charite Campus Virchow, Berlin, Germany
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Lang M, Neumann UP, Müller AR, Bechstein WO, Neuhaus R, Neuhaus P. [Complications of percutaneous liver biopsy in patients after liver transplantation]. Z Gastroenterol 1999; 37:205-8. [PMID: 10234792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
Percutaneous liver biopsy is an important diagnostic tool for the management of patients following liver transplantation. However, it may be associated with severe complications. To evaluate the incidence and type of complications after liver biopsy, we retrospectively analyzed 919 patients who underwent orthotopic liver transplantation (OLT) from September 1988 to May 1998. A total 3,670 biopsies were performed with ultrasound guidance and use of the Menghini needle (1.6 mm diameter). The biopsies were performed according to the protocol on the 7th postoperative day and one, three, five years after OLT, or when clinically indicated. Patients with severe coagulopathy (thrombocytes < 30,000/nl and Quick < 40%) were excluded from this protocol. Biopsy was complicated by bleeding in 13 of 919 patients (1.41%). The incidence of procedure related complications was 13 of 3,670 (0.35%). Five patients showed intrahepatic hematoma, four patients developed a hematothorax, three patients had intraabdominal bleeding and one patient suffered from hemobilia. Seven of 13 patients (53%) required surgical intervention (laparotomy four, thoracotomy two, retransplantation one). Graft dysfunction after liver transplantation requires rapid assessment and specific treatment to achieve good results. Percutaneous liver biopsy is an important procedure in the evaluation and identification of graft dysfunction such as acute rejection, hepatitis reinfection or toxic alterations. From our data we conclude that percutaneous liver biopsy is a safe procedure and advocate is liberal use.
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Affiliation(s)
- M Lang
- Abteilung für Allgemein- und Transplantationschirurgie, Humboldt Universität Berlin
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